-Billing and Affidavits Summary

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1 -Billing and Affidavits Summary Service Provider Total Billed Insurance Paid Patient Paid Adjusted Unrelated C... Balance Affidavit / DWQ Alexander, Linda LPC $ $0.00 $ $0.00 $0.00 $0.00 3/15/16 American Specialty Pharmacy $3, $0.00 $0.00 $0.00 $0.00 $3, No Affidavit; LOP Anesthesia Alliance $21, $0.00 $0.00 $0.00 $0.00 $21, /30/13, 6/30/14 Atlas Neurophysiological $11, $0.00 $0.00 $0.00 $0.00 $11, /18/13, 7/1/14, 12/30/15 Axis Neuromonitoring $23, $0.00 $0.00 $0.00 $0.00 $23, /18/13, 7/1/14, 12/30/15 Bentree Pain Procedure (Cergis) $97, $0.00 $0.00 $0.00 $0.00 $97, /26/15, 1/22/16(incorrect #'s) Bonnet, David MD $ $ $60.00 $ $ $0.00 1/7/16 Center for Pain Relief $1, $0.00 $0.00 $0.00 $0.00 $1, /10/14, 3/14/16 DFW Injury & Rehab $ $0.00 $0.00 $0.00 $0.00 $ /26/15 Elite Medical Group $5, $3, $0.00 $0.00 $0.00 $2, /26/15, 1/14/16 EliteMed Lab $2, $0.00 $0.00 $0.00 $0.00 $2, No Affidavit Ellman Rehab (Regenerative Ortho) $51, $8, $0.00 $ $0.00 $42, /25/15, 1/4/16 Foundation Physicians $3, $0.00 $0.00 $0.00 $0.00 $3, /17/16 Incare Technology $ $0.00 $0.00 $0.00 $0.00 $ /25/13, 5/6/14 LabCorp $ $0.00 $0.00 $ $0.00 $0.00 2/29/16 Lumin Health $176, $12, $ $158, $0.00 $4, /11/16 $4821 = Ins balance $83.54= pt balance Grand total $ MedCap/Dr. Castillon $54, $0.00 $0.00 $0.00 $0.00 $54, /19/13, 1/29/14, 3/3/16 Methodist - Richardson $2, $ $0.00 $0.00 $0.00 $2, No Affidavit Page 1 of 2

2 -Billing and Affidavits Summary Service Provider Total Billed Insurance Paid Patient Paid Adjusted Unrelated C... Balance Affidavit / DWQ Pine Creek Medical Ctr $735, $0.00 $0.00 $735, $0.00 $0.00 6/12/14, 1/12/16 Prime Diagnostic Imaging $27, $0.00 $0.00 $0.00 $0.00 $27, /27/15; 1/25/16 Radiology Associates $ $0.00 $0.00 $44.00 $0.00 $ /24/16; to Collections Remed $8, $3, $0.00 $0.00 $0.00 $5, /26/15, 1/14/16 Roman, Antonio MD $ $ $60.00 $88.21 $0.00 $ /12/16 Safeway Pharmacy $ $0.00 $88.35 $0.00 $0.00 $ /9/16, insurance paymts etc not on DWQ Stanley, James MD $1, $0.00 $0.00 $0.00 $0.00 $1, /3/15 Star Medical Center $624, $215, $0.00 $0.00 $0.00 $408, /20/15, 1/26/16 Tx Neurospine Institute $41, $0.00 $0.00 $0.00 $0.00 $41, /2/15, 12/21/15 UMC $2, $0.00 $0.00 $1, $0.00 $1, /4/16 The appears to have been turned in as "bad debt" Up and Open Imaging $10, $0.00 $0.00 $3, $0.00 $6, /27/15, 2/9/16 UT Southwestern $ $ $0.00 $ $0.00 $0.00 No Affidavit Village Physical Therapy $3, $ $0.00 $0.00 $0.00 $3, /29/15, 1/5/16 Walmart $ $0.00 $0.00 $0.00 $0.00 $ /23/16 Z&Z Medical Associates $3, $0.00 $0.00 $0.00 $0.00 $3, /30/14(2), 6/30/14 GRAND TOTAL $1,916, $245, $ $899, $ $770, Page 2 of 2

3 1 Bala Giri, MD Tx Neurospine Inst. 2/17/14 $ $0.00 $0.00 $0.00 $ New patient consult 3/7/14 $ $0.00 $0.00 $0.00 $ Office visit 5/21/14 $40, $0.00 $0.00 $0.00 $40, Giri - Lumbar surgery Jennifer Moore - Assist Spondylolisthesis Spondylolisthesis 10/6/14 $ $0.00 $0.00 $0.00 $ Office visit 10/24/14 $ $0.00 $0.00 $0.00 $ Office visit Subtotal $41, $0.00 $0.00 $0.00 $41, UMC 5/14/13 $2, $0.00 $0.00 $1, $0.00 $1, Ambulance - MVA Emergency Center Services Lumbosacral x-ray Radiology Associates 9/26/13 $40.00 $0.00 $0.00 $0.00 $ Chest x-ray V72.83 Preop procedure 4/9/14 $40.00 $0.00 $0.00 $0.00 $ Chest x-ray V72.83 Preop procedure 5/22/14 $44.00 $0.00 $0.00 $44.00 $ Lumbosacral x-ray V72.83 Preop procedure Subtotal $ $0.00 $0.00 $44.00 $ sent to collections James Stanley, MD 1/16/14 $1, $0.00 $0.00 $0.00 $1, New patient consult Z&Z Medical Assoc. Berto Zamora, MD 3/19/14 $1, $0.00 $0.00 $0.00 $1, New patient consult EKG Lab Lumbago V72.81 Preop Exam Spondylolysthesis 4/9/14 $ $0.00 $0.00 $0.00 $ EKG V72.81 Preop Exam 5/22/14-5/23/14 $1, $0.00 $0.00 $0.00 $1, Subtotal $3, $0.00 $0.00 $0.00 $3, Initial Hospital visit Subsequent hospital visit Spondylolysis Oliguria Lumbago Constipation Anesthesia Alliance 10/7/13 $11, $0.00 $0.00 $0.00 $11, Anesthesia - cervical spine Cervical disc displacemt 5/21/14 $9, $0.00 $0.00 $0.00 $9, Anesthesia - lumbar spine Subtotal $21, $0.00 $0.00 $0.00 $21, Pine Creek Medical 9/26/13 $ $0.00 $0.00 $ $0.00 Pre-op Lab, xray Cervical disc displacemt

4 2 Michael Ellman, MD Regenerative Ortho 10/7/13-10/8/13 $533, $0.00 $0.00 $533, $0.00 Cervical surgery - all supplies, drugs, OR and anesthesia Cervical disc displacemt 4/9/14 $ $0.00 $0.00 $ $0.00 Pre-op Lab, xray V72.83 Preop procedure 4/30/14 $1, $0.00 $0.00 $1, $0.00 Pharmacy/supplies 5/21/14 $199, $0.00 $0.00 $199, $0.00 Subtotal $735, $0.00 $0.00 $735, $0.00 Lumbar surgery - all supplies, drugs, OR and anesthesia 6/27/13 $ $0.00 $0.00 $0.00 $ Office consult - mod-high 7/10/13 $3, $0.00 $0.00 $0.00 $3, Cervical & trigger point injections 7/17/13 $5, $ $0.00 $0.00 $5, Lumbar and ligament injections 8/13/13 $ $ $0.00 $0.00 $ Established pt office visit 8/21/13 $6, $ $0.00 $0.00 $5, Cervical & trigger point injections 8/27/13 $ $ $0.00 $0.00 $ Office visit - moderate 9/4/13 $15, $ $0.00 $0.00 $14, SI joint and ligament injections 11/25/14 $ $ $0.00 $0.00 $90.00 Office visit - low 12/3/14 $5, $4, $0.00 $0.00 $1, Lumbar & trigger point injections; Epiduragram 12/11/14 $ $0.00 $0.00 $0.00 $ Office visit - low 1/15/15 $ $0.00 $0.00 $0.00 $ Office visit - low 1/26/15 $7, $0.00 $0.00 $0.00 $7, Office visit - low, EMG 3/26/15 $ $ $0.00 $0.00 $0.00 Office visit - moderate 4/30/15 $ $ $0.00 $0.00 $0.00 Office visit - low 5/28/15 $ $ $0.00 $0.00 $0.00 Office visit - low 6/25/15 $ $0.00 $0.00 $0.00 $ Office visit - moderate 7/1/15 $ $0.00 $0.00 $0.00 $ Office visit - moderate 7/22/15 $ $0.00 $0.00 $0.00 $ Office visit - low 8/19/15 $ $0.00 $0.00 $0.00 $ Office visit - low 9/16/15 $ $0.00 $0.00 $0.00 $ Office visit - low 10/14/15 $ $0.00 $0.00 $0.00 $ Office visit- Established pt 11/18/15 $ $0.00 $0.00 $0.00 $ Office visit - moderate 12/16/15 $ $45.02 $0.00 $ $ Office visit - low

5 3 1/20/16 $ $0.00 $0.00 $0.00 $ Subtotal $51, $8, $0.00 $ $42, InCare Technology 10/7/13 $ $0.00 $0.00 $0.00 $ Cervical collar Cervical disc displacemt Atlas Neurophysiological Assessment 10/7/13 $5, $0.00 $0.00 $0.00 $5, /21/14 $5, $0.00 $0.00 $0.00 $5, Subtotal $11, $0.00 $0.00 $0.00 $11, Axis Neuromonitoring 10/7/13 $12, $0.00 $0.00 $0.00 $12, /21/14 $10, $0.00 $0.00 $0.00 $10, Subtotal $23, $0.00 $0.00 $0.00 $23, Intraoperative neuromonitoring Cervical radiculopathy Dr. Hird's charges Cervical disc displacemt Intraoperative neuromonitoring Cervical radiculopathy Dr. Hird's charges Cervical disc displacemt Intraoperative neuromonitoring Cervical radiculopathy Jennifer Onge charges Cervical disc displacemt Intraoperative neuromonitoring Thoracic radiculopathy Jennifer Onge charges Center for Pain Relief 5/21/14 $ $0.00 $0.00 $0.00 $0.00 $ Hospital visit Post procedural pain 5/22/14 $ $0.00 $0.00 $0.00 $0.00 $ Hospital visit Post procedural pain 1/13//16 $ $0.00 $0.00 $0.00 $0.00 $ New patient consult Subtotal $1, $0.00 $0.00 $0.00 $0.00 $1, MedCap Frank Castillon, MD *Note: there are 2 affidavits; one for Medcap and one for Castillon but they are the same charges 6/24/13 $ $0.00 $0.00 $0.00 $ New patient consult 8/22/13 $ $0.00 $0.00 $0.00 $ Office visit 10/7/13 $53, $0.00 $0.00 $0.00 $53, Cervical surgery Subtotal $54, $0.00 $0.00 $0.00 $54, Thoracic radiculopathy Lumbosacral disc displacemt Spondylolisthesis Spondylolysis Cervical radiculopathy Cervical disc displacemt Spondylosis Lumbago Cervical radiculopathy Cervical disc displacemt Spondylosis Lumbago Star Medical Center 3/4/15-3/6/15 $624, $215, $0.00 $0.00 $0.00 $408, Lumbar surgery - all supplies, drugs, OR and anesthesia

6 4 Up and Open Imaging (JTP) Cergis (Bentree Pain Procedure Center) 5/21/13 $5, $0.00 $0.00 $0.00 $5, Lumbar MRI Lumbago 1/24/14 $4, $0.00 $0.00 $3, $1, Lumbar MRI Lumbago Subtotal $10, $0.00 $0.00 $3, $6, /10/13 $11, $0.00 $0.00 $0.00 $11, Cervical & trigger point injections 7/17/13 $15, $0.00 $0.00 $0.00 $15, Lumbar and ligament injections 8/21/13 $22, $0.00 $0.00 $0.00 $22, Cervical & trigger point injections 9/4/13 $32, $0.00 $0.00 $0.00 $32, SI joint and ligament injections 12/3/14 $15, $0.00 $0.00 $0.00 $15, Subtotal $97, $0.00 $0.00 $0.00 $97, Lumbar & trigger point injections; Epiduragram Lumin Health 1/8/15 $1, $0.00 $0.00 $0.00 $1, Samir Desai, PA New patient consult This charge is higher than customary for this service code/specialty Bone/cartilage disorder Radiculitis 2/17/15 $1, $0.00 $30.00 $0.00 $1, /27/15 $1, $64.41 $30.00 $ $0.00 Dr. Won Office visit Transfer from insurance to patient: Samir Desai, PA Office visit This charge is higher than customary for this service code/specialty Congenital lumbosacral spondylolysis Lumbar postlaminectomy syndrome lumbosacral neuritis Spondylolisthesis Lumbosacral radiculitis 2/27/15 $17, $1, $0.00 $14, $ Dr. Won LSO brace - $11,690 Walker - $995 Pneumatic compressor and appliance x4- $995 EACH-$3980 Orthotics training - $ Spondylolisthesis Lumbosacral radiculitis

7 5 3/1/15 $1, $98.27 $0.00 $1, $0.00 3/4/15 $29, $3, $0.00 $25, $0.00 3/4/15 $52, $4, $0.00 $47, $0.00 Preop eval - Sandy Stetz PA Lab tests EKG X-ray is amount owed by Pt. Dr. Won 1. Lumbar arthrodesis, posterior segmental instrumentation, and allograft 2. Vertebral corpectomy with decompression, Arthrodesis with mini discectomy, intervertebral biomechanical device, vertebral corpectomy, allograft, bone marrow aspiration 3/4/15 $15, $1, $0.00 $14, $ Explore fusion, remove rod 3/4/15 $28, $ $0.00 $27, $0.00 3/4/15 $15, $ $0.00 $15, $0.00 N Tx 1st Assist - Samir Desai, PA Arthrodesis- lumbar, Posterior segmental instrumentation N Tx 1st Assist - Samir Desai, PA Spinal fusion exploration Removal of instrumentation Muscle spasm Backache Congenital lumbosacral spondylolysis Congenital lumbosacral spondylolysis Congenital lumbosacral spondylolysis Congenital lumbosacral spondylolysis Congenital lumbosacral spondylolysis 3/18/15 $ $0.00 $0.00 $ $ /31/15 $0.00 $0.00 $0.00 $0.00 $0.00 Lumbosacral x-ray; Samir Desai, PA Post-op follow-up: no charge Dr. Won Post-op follow-up: no charge Spondylolisthesis Post-op infection Post-lami syndrome Lumbosacral radiculitis

8 6 4/10/15 $ $26.66 $0.00 $ $0.00 4/21/15 $1, $65.76 $30.00 $1, $0.00 4/28/15 $ $23.10 $0.00 $ $0.00 4/30/15 $ $54.90 $30.00 $ $0.00 5/5/15 $ $26.75 $0.00 $ $0.00 5/7/15 $ $26.75 $0.00 $ $0.00 5/12/15 $ $26.75 $30.00 $ $0.00 5/14/15 $ $54.90 $30.00 $ $0.00 5/19/15 $1, $70.59 $0.00 $1, $0.00 5/21/15 $ $10.53 $0.00 $ $0.00 Samir Desai, PA Lumbosacral x-ray; Post-op office follow-up included at no charge New pt eval Self-care training procedures Therapeutic exercise Spondylolisthesis Lumbar non-allopathic lesions Lumbar lesions Lumbar lesions Lumbar lesions

9 7 5/28/15 $ $54.90 $0.00 $ $0.00 6/2/15 $1, $70.59 $0.00 $1, $0.00 6/4/15 $1, $70.59 $30.00 $1, $0.00 6/9/15 $1, $77.47 $30.00 $1, $0.00 7/21/15 $1, $0.00 $0.00 $0.00 $1, /6/15 $1, $ $30.00 $ $ /18/15 $ $ $0.00 $ $ Office visit / Discharge procedures Dr. Won Office visit Lumbosacral x-ray This charge is higher than customary Office visit This charge is higher than customary for this service code/specialty Dr. Neerav Bhatla (pain management) New patient evaluation Subtotal $176, $12, $ $158, $4, = Insurance balance = Patient balance Total balance = DFW Injury & Rehab 1/22/14 $ $0.00 $0.00 $0.00 $ Office visit 2/17/14 $ $0.00 $0.00 $0.00 $ Office visit 3/26/14 $ $0.00 $0.00 $0.00 $ Office visit Subtotal $ $0.00 $0.00 $0.00 $ Prime Diagnostic Imaging Post laminec syndrome Chronic Pain Syndrome Spondylolisthesis, acquired Cervical spinal stenosis Post laminec syndrome Lumbosacral radiculitis Cervical disc displacemt Cervical spinal stenosis G89.4 Chronic Pain syndrome M96.1 Post-laminectomy M48.06 Lumbar spinal stenosis M43.16 Lumbar spondylolisthesis 5/23/13 $4, $0.00 $0.00 $0.00 $0.00 $4, Cervical & thoracic MRI Lordosis, acquired Thoracic spondylosis 8/7/13 $ $0.00 $0.00 $0.00 $0.00 $ Lumbosacral x-ray Lumbar disc degeneration 11/22/13 $ $0.00 $0.00 $0.00 $0.00 $ Cervical x-ray Cervicalgia 6/10/14 $ $0.00 $0.00 $0.00 $0.00 $ Lumbosacral x-ray

10 8 7/18/14 $ $0.00 $0.00 $0.00 $0.00 $ Lumbosacral x-ray 10/6/14 $ $0.00 $0.00 $0.00 $0.00 $ Lumbosacral x-ray 10/13/14 $3, $0.00 $0.00 $0.00 $0.00 $3, Lumbar MRI Lumbar disc degeneration 2/2/15 $3, $0.00 $0.00 $0.00 $0.00 $3, Spinal myelogram 2/2/15 $3, $0.00 $0.00 $0.00 $0.00 $3, Cervical and Lumbar CT 8/3/15 $5, $0.00 $0.00 $0.00 $0.00 $5, Cervical and Lumbar MRI 8/3/15 $1, $0.00 $0.00 $0.00 $0.00 $1, Lumbar CT 8/3/15 $4, $0.00 $0.00 $0.00 $0.00 $4, Lumbosacral myelogram Subtotal $27, $0.00 $0.00 $0.00 $0.00 $27, office visit -new patient Elite Medical Group 5/20/13 $1, $ $0.00 $0.00 $ TENS unit Self-care training (TENS) 5/22/13 $ $ $0.00 $0.00 $ Office visit 5/29/13 $ $ $0.00 $0.00 $ Office visit 6/10/13 $ $ $0.00 $0.00 $ Office visit 6/20/13 $3, $1, $0.00 $0.00 $1, Office visit EMG/NCV 7/3/13 $ $ $0.00 $0.00 $ Office visit 7/29/13 $ $ $0.00 $0.00 $ Office visit 8/14/13 $ $94.70 $0.00 $0.00 $77.30 Office visit 9/11/13 $ $ $0.00 $0.00 $ Office visit Subtotal $5, $3, $0.00 $0.00 $2, Remed 5/20/13 $ $0.00 $0.00 $0.00 $ PT eval and therapy Thoracic sprain Neck sprain Lumbar sprain Vascular headache 5/22/13 $ $0.00 $0.00 $0.00 $ Therapy Same as above 5/23/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 5/29/16 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 5/30/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 5/31/13 $ $22.76 $0.00 $0.00 $ Therapy Same as above 6/3/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 6/5/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 6/7/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 6/10/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 6/12/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 6/14/13 $ $ $0.00 $0.00 $ Therapy Same as above 6/18/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above

11 9 6/19/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 6/20/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 6/25/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 7/1/13 $ $0.00 $0.00 $0.00 $ Therapy Same as above 7/2/13 $ $0.00 $0.00 $0.00 $ Therapy Same as above 7/3/13 $ $0.00 $0.00 $0.00 $ Therapy Same as above 7/9/13 $ $0.00 $0.00 $0.00 $ Therapy Same as above 7/15/13 $ $0.00 $0.00 $0.00 $ Therapy Same as above 7/19/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 7/23/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 7/25/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 7/26/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 7/30/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 7/31/13 $ $ $0.00 $0.00 $ Therapy Same as above 8/8/13 $ $89.08 $0.00 $0.00 $ Therapy Same as above 8/9/13 $ $61.62 $0.00 $0.00 $ Therapy Same as above 8/12/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 8/14/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 8/16/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 8/19/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 8/23/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 8/26/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 8/29/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 9/3/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 9/6/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 9/9/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 9/11/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 9/13/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 9/16/13 $ $ $0.00 $0.00 $ Therapy Same as above 9/19/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 9/23/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 9/26/13 $1, $ $0.00 $0.00 $ Therapy Same as above 10/1/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above 10/3/13 $ $50.46 $0.00 $0.00 $94.54 Therapy Same as above Subtotal $8, $3, $0.00 $0.00 $5, Village PT 8/5/14 $ $0.00 $0.00 $0.00 $ OT Initial Eval 8/11/14 $ $0.00 $0.00 $0.00 $ Therapy

12 10 8/14/16 $ $0.00 $0.00 $0.00 $ Therapy 8/20/16 $ $0.00 $0.00 $0.00 $ Therapy 8/21/14 $ $0.00 $0.00 $0.00 $ Therapy 8/22/14 $ $0.00 $0.00 $0.00 $ Therapy 8/25/14 $ $0.00 $0.00 $0.00 $ Therapy 8/27/14 $ $0.00 $0.00 $0.00 $ Therapy 8/28/14 $ $0.00 $0.00 $0.00 $ Therapy 9/4/15 $ $0.00 $0.00 $0.00 $ Therapy 9/5/14 $ $0.00 $0.00 $0.00 $ Therapy 9/8/14 $ $0.00 $0.00 $0.00 $ Therapy 9/10/14 $ $0.00 $0.00 $0.00 $ Therapy 9/12/14 $65.00 $0.00 $0.00 $0.00 $65.00 Therapy 8/4/15 $1, $ $0.00 $0.00 $ FCE Subtotal $3, $ $0.00 $0.00 $3, UT Southwestern 3/19/14 $ $ $0.00 $ $0.00 Cardiac Clearance - radiology V72.83 Preop procedure LabCorp 3/1/15 $ $0.00 $0.00 $ $0.00 Preop lab V72.83 Preop procedure Methodist - Richardson 3/20/15 $2, $ $0.00 $0.00 $2, Unknown - not on statement Elitemed Lab 5/28/15 $2, $0.00 $0.00 $0.00 $2, Lab work Lumbago Antonio Roman, MD 5/21/15 $ $ $30.00 $68.77 $ New pt consultation 6/25/15 $85.00 $75.28 $30.00 $9.72 $ Office visit 8/25/15 $85.00 $75.28 $0.00 $9.72 $ Office visit 12/22/15 $85.00 $25.00 Pt total shows Not sure why. Should be Subtotal $ $ $60.00 $88.21 $25.00 David Bonnet, MD 12/3/13 $60.00 Vaccines V04.81 Vaccine encounter 7/29/14 $ $46.72 $30.00 $23.28 $ Office visit Allergic reaction 7/31/14 $ $69.77 $30.00 $ $ Office visit, Steroid injection Uticaria [skin rash] 9/22/15 $ Office visit - Upper Resp. Infec Upper Resp. Infection Subtotal $ $ $60.00 $ $ $0.00 Foundation Physicians 2/3/26 $3, $0.00 $0.00 $0.00 $0.00 $3, Psych eval and testing Linda Alexander, LPC 7/16/15 $ $0.00 $ $0.00 $0.00 $ Psychotherapy Safeway Pharmacy 3/6/15 $ $0.00 $8.59 $0.00 $0.00 $ Hydromorphone, Oxycontin 3/19/15 $4.87 $0.00 $4.87 $0.00 $0.00 $0.00 Hydromorphone 9/22/15 $ $0.00 $30.00 $0.00 $0.00 $ Oxycontin 10/16/15 $14.89 $0.00 $14.89 $0.00 $0.00 $0.00 Hydrocodone 10/19/15 $ $0.00 $30.00 $0.00 $0.00 $ Oxycontin

13 11 Subtotal $ $0.00 $88.35 $0.00 $0.00 $ Walmart Pharmacy 10/8/13 $46.62 $0.00 $0.00 $0.00 $0.00 $46.62 American Specialty Pharmacy 7/1/15 $58.75 $0.00 $0.00 $0.00 $0.00 $58.75 Subtotal $ $0.00 $0.00 $0.00 $0.00 $ /4/15 $1, LOP $0.00 $0.00 $0.00 $1, /28/15 $2, LOP $0.00 $0.00 $0.00 $2, Subtotal $3, $0.00 $0.00 $0.00 $0.00 $3, Alprazolam, Hydrocodone, Methocarbam Diazepam, Hydrocodone, Tizanidine Oxycontin, Norco (hydrocodone) Oxycontin, Norco (hydrocodone) DWQ does not show Insurance paymts, unpaid etc so I only deducted the patient payments Grand Totals $1,916, $245, $899, $ $770,910.44

ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 4 of 10 Instructor: Paul Sherman, DC

Online Continuing Education Courses www.onlinece.com www.chirocredit.com ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 4 of 10 Instructor: Paul Sherman, DC Important Notice: This download